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Patient Satisfaction Following Closed Reduction of

Nasal Bone Fracture

By

Ahmad Al Arfaj, MD Associate Professor and Consultant Department of Otorhinolaryngology

Medical College King Saud University

Saudi Arabia

Yasin S. Subhan, MD Registrar, Department of ORL-HNS King Abdulaziz University Hospital

King Saud University, KSA

Tareq Al Otaibi, MD Fellow, Department of ORL-HNS

King Abdulaziz University Hospital King Saud University, KSA

Amani Ahmed Obeid, MD

Asst. Consultant, Department of ORL-HNS King Abdulaziz University Hospital

King Saud University, KSA

Address for correspondence: Dr. Ahmad Al Arfaj Department of Otorhinolaryngology King Abdel Aziz Hospital P.O. Box 245, Riyadh 11411, Saudi Arabia. E mail:amarfaj@hotmail.com Tel: + 966 11 4775735 Fax: + 996 11 4775748

Financial Disclosure: No grants or financial support used for the completion of this

study.

Conflict of Interest: None declared

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ABSTRACT

Objective:

To present the clinical profile of patients subjected to closed reduction of fractured

nasal bone and review the outcome of the procedure from the patient’s perspective.

Methods:

Patients with nasal bone fracture treated with closed reduction in King Abdulaziz

University Hospital, Riyadh between 1 January 2008 and 31 December 2013 were

included. The essential data consisting of personal details, history, examination, details

of surgical corrections were charted. Patients were followed-up by a telephonic

interview to obtain their level of satisfaction of the outcome.

Results:

Of the 163 patients who were studied, 147 patients could be successfully contacted and

interviewed, and 16 patients could not be contacted. Of the 147 patients, 65 (44%)

patients expressed full satisfaction with the functional and aesthetic outcome; 42 (29%)

patients were partially satisfied but would not consider revision surgery; 39 (27%)

patients were not satisfied and would consider revision surgery.

Conclusion:

Despite a relatively high patient satisfaction rate with the functional and aesthetic

outcome of closed reduction of nasal fracture, a significant number of patients (27%)

are unsatisfied. A thorough pre-operative evaluation of the nasal deformity including

presence of pre-existing deformities and meticulous surgical correction might reduce the

rate of the unsatisfactory outcome of the primary surgical procedure.

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INTRODUCTION

Fracture nasal bone is a common condition generally treated by closed reduction. It is

a simple maneuver carried out under local or general anesthesia and in many

occasions performed by junior surgeons. Few studies have evaluated the functional

and the cosmetic outcome of the procedure. The reported success rates ranged

between 62 and 80 %.1-4 The purpose of this study is to present the age, sex, the

causes and the treatment outcome of fracture nasal bone cases treated in King

Abdulaziz Hospital, Riyadh over a 6 years period.

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MATERIALS & METHODS

A review of the Health Information System (HIS) was done to pull out all the files of

patients who were diagnosed as fracture of nasal bone in King Abdul Aziz University

Hospital, King Saud University from 1 January 2008 to 31 December 2013.

Of all the 190 cases, 163 had undergone closed reduction. After approval from the IRB

committee the files were retrieved and all these patients were called on the telephone.

The author was able to review 147 patients, and the remaining 16 patients could not be

contacted. The caller would introduce himself and explain the study and take verbal

consent for their participation in the study. He would then ask a fixed format of

questions about the outcome and enter it in the datasheet. Those datasheets would

then be completed from information gathered from the file including type of trauma, date

of presentation post trauma, presenting complaints etc. All the data was statistically

analyzed using SPSS Software, Version 16.2008.

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RESULTS

The total number of patients with nasal trauma enrolled in this study was147; the mean

age (3-39 years) was 17.5years. The male group was 77.6% (N=114) while the female

group was 22.4% (N=33). The cause of the trauma is shown in table 1. Football was the

most common cause of nasal trauma in the male group (31.6%) while fall was the most

common cause in female patients (48.5%). Patients presented to otolaryngology clinic

more than 1 week after trauma were 72 patients (49%). The presenting features of the

patients are shown in Table 2. The number of patient who complained of preoperative

nasal deformity was 141 (96%). Depressed fracture was diagnosed in 62 patients

(42.2%). The number of patients who had nasal obstruction due to trauma were 30

patients (20.4%). The number of the patients who had radiological study was 117

(79.6%). The surgical procedure was done by residents with consultant supervision in

136 cases (92.5%). One hundred and thirty patients (88.4%) had no packing post

surgery; while 16 patients (10.9%) had post-operative packing. The overall satisfaction

rate is shown in table 3.

Of the patient who had nasal obstruction, about 40% (12) of the patients expressed total

satisfaction and 30% (N=9) were partially satisfied but not seeking other surgery; while

30%(N=9) were totally unsatisfied and were looking for further treatment.

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DISCUSSION

The central position of the nose and its anterior projection on the face make it

susceptible to injury, and therefore fractures of the nasal bones are the most common

facial fractures and the third most common of the human skeleton5. The main

etiologies of nasal fractures worldwide are falls, violence, traffic accidents, and sport

injuries.6 The number of cases of nasal bone fracture has been increasing with the

increase in the number of injuries or car accidents.7

Most cases of nasal bone fracture can be diagnosed clinically by a routine nasal

examination especially in the presence of crepitus and tenderness in palpation.

However, radiological investigation plays an important part in the diagnosis and

evaluation of nasal bone fractures. Most nasal bone fractures can be diagnosed with

plain X ray and/or with computed tomography (CT). Radiography is also required for

accurate treatment and postoperative evaluation.8 Although many authors have

described classification systems for nasal fractures, there is no uniform system has

been universally advocated or applied. Stranc9 described a classification system that is

often cited in the literature. There is an increasing necessity for a satisfactory

classification systems for nasal fractures.

There are several methods used for treating fractures of nasal bone including closed

reduction, open reduction and septo-rhinoplasty. Closed reduction is the most common

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procedure used; that involves manipulation of nasal bones without incisions and

performed either under local or anesthesia.

This retrospective study is carried out on 147 patients treated by closed reduction done

under general anesthesia over a 6 years period. The male group were more involved in

nasal trauma than females; by ratio of 3.4:1. This ratio is within the range described in

the literature, which varied between 6:1 and 11.8:1.10,11,12 This high vulnerability of

male to most types of trauma may be associated with the fact that male have more

outdoor activities and are involved in high risk jobs, thus being more vulnerable to

accidents.

Many etiological factors have been associated with nasal bone fracture. In this study fall

was the most common overall cause while football injury is the most common cause in

the male group.

Analysis of the treatment results showed that about 44.2% of patients in this study were

satisfied with closed reduction. Another 28.6% of the patients had some postoperative

deformity but were not seeking further surgery. On the other hand, 26.5% of patients

were totally unsatisfied and were looking for rhinoplasty procedure. The findings are

comparable with 80% reported by Wild et al3, 71% reported by Watson et al4 and by

65% by Yilmaz1 in adults and 62% in children.2 Similarly, in a study by Hung, 29% of

patients were dissatisfied with closed reduction13.These rather disappointing

postoperative results indicate the need for improvement of our approach in the

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management of this common problem. Beekhuis advised to proceed for

septorhinoplasty with osteotomy which have high percentage of straight nose then

closed reduction.14 The optimal timing of closed reduction is not clear and varies

throughout the literature.15,16 Generally, reduction should be done as soon as possible.

The presence of edema might delay the reduction few days. In this study, patients

presented later than 7 days for closed reduction have a high satisfaction rate than

patient presented early for intervention. This could be due to the fact that presence of

edema may adversely affect the outcome.

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CONCLUSION

Closed reduction of fractured nose is a common procedure. However, the functional and

the cosmetic results may not be satisfactory to a large section of the patients. A more

thorough technique is required in order to achieve better outcome.

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References

1. Yimaz MS, Guven M, Verli AF. Nasal fractures: is closed reduction satisfying? J

Craniofac Surg 2013;24:e36-8.

2. Yimaz MS, Guven M, Verli AF: Efficacy of closed reduction for nasal fracture in

children.Br J oral Maxill Surg 2013:51 e256-e258:

3. Wild DC, EL Alami Conboy Reduction of nasal fractures under local

anaesthesia: an acceptable practice? 2003 Sur J R Coll Surg Edinb Irel 1:45-47

4. Watson DJ, Parker AJ, Slack RW, Griffiths MV. Local versus general

anaesthesia in the management of fractured nose. Clin Otolaryngol 1988; 13:

491-94

5. Murray JA, Maran AG, Mackenzie IJ, Raab G. Open v closed reduction of the

fractured nose. Arch Otolaryngol 1984;110:797–802.

6. 4. Scariot R, de Oliveira IA, Passeri LA, Rebellato NL, Müller PR. Maxillofacial

injuries in a group of Brazilian subjects under 18 years of age. J Appl Oral Sci

2009;17:195-8.

7. Atighechi S, Karimi G: Serial nasal bone reduction: A new approach to the

management of nasal bone fracture. J Craniofac Surg 20:49, 2009.

8. Yabe T, Ozawa T, Sakamoto M, et al: Pre- and postoperative x-ray and

computed tomography evaluation in acute nasal fracture. Ann Plast Surg

53:547, 2004.

9. Stranc MF, Robertson GA: A classification of injuries of the nasal skeleton. Ann

Plast Surg 2:468-474, 1979.

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10. Hächl O, Tuli T, Schwabegger A, Gassner R. Maxillofacial trauma due to work-

related accidents. Int J Oral MaxillofacSurg 2002;31:90-3.

11. Pombo M, Luaces-Rey R, Pértega S, Arenaz J, Crespo JL, García-Rozado A, et

al. Review of 793 facial fractures treated from 2001 to 2008 in a coruña university

hospital: types and etiology. Craniomaxillofac Trauma Reconstr 2010;3:49-54.

12. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma,Prasad R. The

pattern of the maxillofacial fractures – A multicentre retrospective study. J

Craniomaxillofac Surg 2012;40:675-9.

13. Hung, T., Chang, W., Vlastis, AC, et.al. Patient. Satisfaction After Closed

Reduction of Nasal Fractures. Arch facial Plast surg 2007; 9;40-3.

14. Beekhuis, G., (1970). Symposium: Maxillofacial trauma, nasal fracture. Am Acad

Ophthalmol Otol 74:1058-1059.

15. Descrosiers III AE, Thaller SR. Paediatric Nasal Fractures: Evaluation and

Mangement. J Craniofac Surg. 2011;22:1327-9.

16. Lee DH, Jang YJ. Pediatric nasal bone fractures: does delayed treatment really

lead to adverse outcomes Int J Pediatr Otorhinolaryngol 2013;77:726–31.

Address for correspondence: Dr. Ahmad Al Arfaj Department of Otorhinolaryngology King Abdel Aziz Hospital P.O. Box 245, Riyadh 11411, Saudi Arabia. E mail:amarfaj@hotmail.com Tel: + 966 11 4775735 Fax: + 996 11 4775748

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Table 1: The causes of nasal trauma

Fall Down Fight Football Hard

Object

RTA Total

Male 26 24 36 5 23 114

Female 16 4 0 4 9 33

Total 42 28 36 9 32 147

Table 2: The presenting symptoms

Nasal Deformity Bleeding Obstruction

Number Percentage Number Percentag

e Number Percentag

e No 6 4.1 45 30.6 117 79.6 Yes 141 95.9 102 69.4 30 20.4 Total 147 100.0 147 100.0 147 100.0

Table 3: The overall satisfaction rate

Number of

patients Percentage

Fully satisfaction 65 44.2 Partial satisfaction 42 28.6 Unsatisfaction 39 26.5 Total 147 100.0